Provider Demographics
NPI:1588700801
Name:WHITNAH, WARREN L
Entity type:Individual
Prefix:DR
First Name:WARREN
Middle Name:L
Last Name:WHITNAH
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:35555 SPARTA LN
Mailing Address - Street 2:
Mailing Address - City:RICHLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97870-6650
Mailing Address - Country:US
Mailing Address - Phone:541-893-6012
Mailing Address - Fax:541-893-6787
Practice Address - Street 1:PINE EAGLE CLINIC
Practice Address - Street 2:218 N. PINE STREET
Practice Address - City:HALFWAY
Practice Address - State:OR
Practice Address - Zip Code:97870
Practice Address - Country:US
Practice Address - Phone:541-742-6012
Practice Address - Fax:541-742-6013
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-30
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR4377122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR4377OtherDENTAL LICENSE #
OR0636682-6OtherSID#
OR210013OtherOMAP PROVIDER #
OR356545OtherDRIVERS LICENSE #